Methods for intra-abdominally moving and holding the liver away from the stomach

ABSTRACT

An apparatus including a flexible length of cord and three tissue connectors positioned at the opposite ends of the cord and at an intermediate position of the cord is designed to be laparoscopically inserted through the abdominal wall and into the abdominal cavity, and used to move a first internal organ to a position away from a second internal organ where the apparatus holds the first internal organ in the position without further manual input, thereby providing surgical access to the second internal organ.

This application is a continuation of U.S. application Ser. No.13/538,075, filed Jun. 29, 2012, now U.S. Pat. No. 8,888,679, which is acontinuation of U.S. application Ser. No. 13/203,396 filed Nov. 11,2011, now U.S. Pat. No. 8,251,889, which is a national stage applicationof International Application PCT/US2010/025425 filed Feb. 25, 2010,which in turn claims priority to U.S. Provisional Application61/155,409, filed Feb. 25, 2009. This application is also a continuationof U.S. application Ser. No. 13/325,575, filed Dec. 14, 2011, which isalso a continuation of U.S. application Ser. No. 13/203,396 filed Nov.11, 2011, now U.S. Pat. No. 8,251,889, which is a national stageapplication of International Application PCT/US2010/025425 filed Feb.25, 2010, which in turn claims priority to U.S. Provisional Application61/155,409, filed Feb. 25, 2009.

FIELD OF THE INVENTION

The present invention is directed to an apparatus and its method of usein intra-abdominally moving a first internal organ to a position awayfrom a second internal organ where the apparatus holds the firstinternal organ in the position without further manual input. Morespecifically, the present invention is directed to an apparatus that isinserted through the abdominal wall and into the abdominal cavity, andthe method of using the apparatus in the abdominal cavity to move ahuman liver to a position away from a human stomach where the apparatusholds the liver in the position without further manual input, therebyproviding surgical access to the stomach.

DESCRIPTION OF THE RELATED ART

In laparoscopic surgical procedures, it is often necessary to makeincisions through the abdominal wall for the sole purpose of providingaccess to the abdominal cavity for surgical graspers or other similartypes of retracting instruments that are used to move one internal organto a position away from a second internal organ to gain surgical accessto the second internal organ. The incisions made for the surgicalgraspers or similar retracting instruments are in addition to theincisions made in the abdominal wall for the surgical instruments usedin performing the surgical procedure on the second organ.

Furthermore, it is often necessary that an additional surgeon orsurgical assistant be present solely for the purpose of manipulating thesurgical graspers or other similar retracting instruments in moving thefirst internal organ to a position away from the second internal organ,and then manually holding the first internal organ in the positionduring the surgical procedure performed on the second internal organ.

The need for the additional surgical personnel to manipulate and holdthe surgical graspers or other similar retracting instruments during thesurgical procedure increases the costs of surgery. In addition, theadditional incisions in the abdominal wall required for the surgicalgraspers or other similar retracting instruments often results inadditional discomfort to the patient following surgery and additionalscarring.

What is needed to overcome these disadvantages associated with theabove-described type of laparoscopic surgical procedure is an apparatusthat can be operated to intra-abdominally move a first internal organ toa position away from a second internal organ and then hold the firstinternal organ in the position without requiring additional manual inputother than that provided by the surgeon and without requiring additionalabdominal incisions other than those required for the surgery.

SUMMARY OF THE INVENTION

The present invention overcomes the above-described shortcomings oflaparoscopic surgical procedures by providing an apparatus that can beinserted into the abdominal cavity through the same incision to be usedin a laparoscopic surgery procedure, and the method of using theapparatus to move or retract a first internal organ, for example theliver, away from a second internal organ, for example the stomach, andthen hold the first internal organ in the retracted position providingsurgical access to the second internal organ without requiring furthermanual input.

The apparatus is constructed of component parts that are often used inlaparoscopic as well as other types of surgical procedures. Thecomponent parts will be described herein using their common understoodnames and their functions, without going into details of the particularconstructions of the component parts.

The basic construction of the apparatus of the invention includes alength of cord. The cord could be comprised of a first cord segmenthaving a flexible length with opposite first and second ends, and asecond cord segment having a flexible length with opposite first andsecond ends. The cord segments could be provided by lengths of suture,lengths of tubing such as IV tubing, lengths of umbilical tape orelastic strips, or other equivalent cord constructions. The first andsecond cord segments could be separate cord segments that are attachedtogether, or could be two cord segments of a single continuous length ofcord.

First, second, and third separate tissue connectors are attached to thefirst and second cord segments. The tissue connectors can be any type ofknown tissue connector that can be manually manipulated to connect tobody tissue, and then manually manipulated to be removed from the bodytissue without leaving any significant damage to the body tissue. Inaddition, the tissue connectors can be biocompatible tissue connectorsthat are designed to be left in the abdominal cavity after the surgery.Some examples of such tissue connectors include suture needles, “T”bars, graspers, barbed needles, hooks, clasps, rivet assemblies, or anyother equivalent type of connector. The first and third tissueconnectors are attached to the opposite ends of the first cord segmentand the second and third tissue connectors are attached to the oppositeends of the second cord segment. This positions the first and secondtissue connectors at the opposite ends of the combined lengths of thefirst and second cord segments, and positions the third tissue connectorat an intermediate position of the combined lengths of the first andsecond cord segments.

In the use of the apparatus according to the method of the invention,the apparatus is first manually passed through the abdominal wall, forexample through an incision or a cannula in the abdominal wall, and ispositioned in the abdominal cavity in the area of the first and secondinternal organs. The third tissue connector is then manually connectedto tissue adjacent the first internal organ. This positions the ends ofthe first and second cord segments connected to the third tissueconnector between the first and second internal organs and on anopposite side of the first internal organ from the abdominal wall. Thefirst tissue connector attached to the opposite end of the first cordsegment from the third tissue connector is manually moved causing thelength of the first cord segment to move and engage across the firstinternal organ and to move the first internal organ toward the positionaway from the second internal organ. The first tissue connector is thenmanually connected to the abdominal wall.

The second tissue connector attached to the opposite end of the secondcord segment from the third tissue connector is then manually movedcausing the second cord segment to move and engage across the firstinternal organ and move the first internal organ toward the positionaway from the second internal organ. The second tissue connector is thenmanually connected to the abdominal wall.

In the above matter, the first and second cord segments engaging acrossthe first internal organ hold the first internal organ at the positionaway from the second internal organ without further manual input. Thisprovides surgical access to the second internal organ.

In a further embodiment of the apparatus of the invention, the apparatusis comprised of a cord having a continuous flexible length with oppositefirst and second ends. A needle is attached to one end of the length ofcord and a knot is formed in the opposite end of the length of cord.

According to the method of use of this embodiment of the apparatus, theapparatus is first positioned inside the abdominal cavity in the samemanner as the previously-described embodiment. The knotted end of thelength of cord is then connected to tissue adjacent the first internalorgan by first passing the needle through the tissue and then manuallypulling the length of cord through the tissue. This attaches the knottedend of the cord to the tissue between the first and second internalorgans.

The needle is then passed through the inter-abdominal wall and manuallymoved back into the abdominal cavity, causing a first segment of thelength of cord to engage across the first internal organ and move thefirst internal organ toward the position away from the second internalorgan.

The needle is then again inserted through the inter-abdominal wall at alocation spaced from the first insertion of the needle through theinter-abdominal wall, and the needle and length of cord are pulledmanually into the abdominal cavity.

The needle and the end of the length of cord attached to the needle arethen passed through the knot formed at the opposite end of the length ofcord and pulled tight, causing a second segment of the length of cord toengage across and move the first internal organ toward the position awayfrom a second internal organ. A knot is then tied between the oppositeends of the length of cord and the portion of the cord extending fromthe knot to the needle is cut and removed with the needle from theabdominal cavity. The length of cord left in the abdominal cavity formsa triangular loop with first and second cord segments that engage acrossand hold the first internal organ in the position away from the secondinternal organ without manual input. In this manner, surgical access isprovided to the second internal organ without manual input.

As described above, the apparatus of the invention and its method of useenable intra-abdominally moving a first internal organ to a positionaway from a second internal organ where the apparatus holds the firstinternal organ in the position without manual input.

DESCRIPTION OF THE DRAWING FIGURES

Further features of the apparatus of the invention and its method of useare set forth in the following detailed description of the apparatus andmethod and are shown in the drawing Figures.

FIG. 1 is a plan view of one embodiment of the apparatus of theinvention.

FIG. 2 is a plan view of a further embodiment of the apparatus of theinvention.

FIG. 3 is a plan view of a still further embodiment of the apparatus ofthe invention.

FIG. 4 is a representation of the apparatus of FIG. 1 being insertedinto the abdominal cavity.

FIG. 5 is a representation of the apparatus of FIG. 1 being usedaccording to the method of the invention.

FIG. 6 is a representation of the apparatus FIG. 2 in use according tothe method of the invention.

FIG. 7 is a representation of the apparatus of FIG. 3 in use accordingto the method of the invention.

FIGS. 8A-8E represent the insertion of one embodiment of the apparatusinto the abdominal cavity and one method of use of the apparatus.

FIGS. 9A-9E represent the insertion of a further embodiment of theapparatus into the abdominal cavity and the method of using theapparatus.

FIGS. 10A and 10B represent the insertion of a further embodiment of theapparatus into the abdominal cavity and the method of using theapparatus.

FIGS. 11A and 11B represent a further embodiment of the apparatus andits method of use.

FIGS. 12A and 12B represent a further embodiment of the apparatus andits method of use.

FIGS. 13A and 13B represent a further embodiment of the apparatus andits method of use.

FIGS. 14A-14C represent a further embodiment of the apparatus and itsmethod of use.

FIGS. 15A and 15B represent a further embodiment of the apparatus andits method of use.

FIGS. 16A and 16B represent a further embodiment of the apparatus andits method of use.

FIG. 17 represents a further embodiment of the apparatus and its methodof use.

FIGS. 18A and 18B represent a further embodiment of the apparatus andits method of use.

FIGS. 19A and 19B represent a further embodiment of the apparatus andits method of use.

FIGS. 20A and 20B represent a further embodiment of the apparatus andits method of use.

FIGS. 21A and 21B represent a further embodiment of the apparatus andits method of use.

FIGS. 22A and 22B represent a further embodiment of the apparatus andits method of use.

FIG. 23 represents a further embodiment of the apparatus and its methodof use.

FIGS. 24A-24C represent component parts of a further embodiment of theapparatus.

FIG. 25 represents a component part of a further embodiment of theapparatus.

FIG. 26 represents a component part of a further embodiment of theapparatus.

FIG. 27 represents a further embodiment of the apparatus

FIG. 28 represents a further embodiment of the apparatus.

FIG. 29 represents a further embodiment of the apparatus.

FIG. 30 represents a further embodiment of the apparatus.

FIG. 31 represents a further embodiment of the apparatus.

FIG. 32 represents a further embodiment of the apparatus.

FIG. 33 represents a component part of an embodiment of the apparatus.

FIG. 34 represents a component part of an embodiment of the apparatus.

FIG. 35 represents a component part of an embodiment of the apparatus.

FIG. 36 represents a component part of an embodiment of the apparatus.

FIG. 37 represents a component part of an embodiment of the apparatus.

FIG. 38 represents a component part of an embodiment of the apparatus.

FIGS. 39A-39C represent component parts of an embodiment of theapparatus.

FIGS. 40A and 40B represent component parts of an embodiment of theapparatus.

FIG. 41 represents a component part of an embodiment of the apparatus.

FIG. 42 represents a component part of an embodiment of the apparatus.

FIG. 43 represents a component part of an embodiment of the apparatus.

FIGS. 44A and 44B represent component parts of an embodiment of theapparatus.

FIGS. 45A-45E represent component parts of an embodiment of theapparatus.

FIGS. 46A-46E represent component parts of an embodiment of theapparatus and its method of use.

FIGS. 47A-47D represent component parts of an embodiment of theapparatus and its method of use.

FIGS. 48A-48D represent component parts of an embodiment of theapparatus and its method of use.

FIGS. 49A and 49B represent component parts of an embodiment of theapparatus and its method of use.

FIGS. 50A and 50B represent component parts of an embodiment of theapparatus and its method of use.

FIGS. 51A-51E represent a method of positioning an embodiment of theapparatus in an abdominal insertion device.

FIGS. 52A and 52B represent embodiments of the apparatus and aninsertion device and the method of mounting the apparatus on theinsertion device.

FIG. 53 represents embodiments of the apparatus and an insertion deviceand a method of mounting the apparatus on the insertion device.

FIG. 54 represents embodiments of the apparatus and an insertion deviceand a method of mounting the apparatus in the insertion device.

FIGS. 55A-55C represent an embodiment of the apparatus and a method ofusing the apparatus.

DETAILED DESCRIPTION

FIG. 1 shows one embodiment 12 of the apparatus for intra-abdominalmoving a first internal organ to a position away from a second internalorgan and then holding the first internal organ in the position withoutmanual input. As stated earlier, the apparatus 12 is constructed ofcomponent parts that are often used in laparoscopic instruments andprocedures as well as other types of surgical instruments andprocedures. Because such component parts are known, the component partsthat make up the apparatus 12 of the invention will be described hereinusing their common understood names and functions, without going intothe details of the particular constructions of the component parts. Asis conventional with laparoscopic apparatus, the component parts of theapparatus are dimensioned to be inserted through an incision in theabdominal wall or through a cannula extending through the abdominal wallto position the apparatus in the abdominal cavity.

The basic construction of the apparatus 12 of the invention includes alength of cord. In the example of FIG. 1 the cord length is 10 inches,but the size of the apparatus 12 could change depending on the size ofthe patient in which the apparatus is used. In the embodiment shown inFIG. 1, the cord is comprised of a first cord segment 14 having aflexible length with opposite first 16 and second 18 ends, and a secondcord segment 22 having a flexible length with opposite first 24 andsecond 26 ends.

The cord segments 14, 22 could be provided by lengths of suture, lengthsof tubing such as IV tubing, lengths of umbilical tape or elasticstrips, or other equivalent cord constructions. The tubing or tapeconfigurations of the cord segments have the advantage of being lesslikely to dig into or cut into the first internal organ in use of theapparatus to be described. The first 14 and second 22 cord segmentscould be separate cord segments that are attached directly together, orseparate cord segments that are attached by way of a further cordsegment 28 or some other component part of the apparatus, or two cordsegments of a single continuous length of cord such as the two cordsegments 14 a, 22 a shown in FIG. 2.

First 32, second 34, and third 36 separate tissue connectors areattached to the first 14 and second 22 cord segments. The tissueconnectors 32, 34, 36 can be any type of known tissue connector that canbe manually manipulated to connect to body tissue, and then manuallymanipulated to be removed from the body tissue without leaving anysignificant damage to the body tissue. In addition, the tissueconnectors 32, 34, 36 could be biocompatible tissue connectors that aredesigned to be left in the abdominal cavity after the surgical procedureis completed. Some examples of tissue connectors include suture needles,“T” bars, surgical graspers, barbed needles, hooks, clasps, rivetassemblies, or any other equivalent type of connector. In the apparatusof the invention, it is not necessary that all three tissue connectors32, 34, 36 be the same type of tissue connector. Because variousdifferent types of tissue connectors may be employed with the apparatus12 of the invention, the three tissue connectors 32, 34, 36 of theapparatus 12 are represented schematically in the drawing Figures. Thefirst 32 and third 36 tissue connectors are attached to the oppositeends of the first cord segment 14. The third tissue connector 36 is alsoattached to one end of the second cord segment 22, with the secondtissue connector 34 being connected to the opposite end of the secondcord segment 22. This positions the first 32 and second 34 tissueconnectors at the opposite ends of the combined lengths of the first 14and second 22 cord segments, and positions the third tissue connector 30at an intermediate position of the combined length of the first 14 andsecond 22 cord segments. In FIG. 1, the first 32 and second 34 tissueconnectors are shown connected to the respective first end 16 of thefirst cord segment 14 and the first end 24 of the second cord segment 22through the intermediary of additional cord segments 38, 40. The thirdtissue connector 36 is shown connected to the second end 18 of the firstcord segment 14 and the second end 26 of the second cord segment 22through the intermediary of a further cord segment 28. FIG. 2 shows theapparatus 12 with the first 32 and second 34 tissue connectors connecteddirectly to the respective first end 16 of the first cord segment 14 andthe first end 24 of the second cord segment 22, FIG. 2 also shows thethird tissue connector 36 connected directly to the second ends 18, 26of the first cord segment 14 and the second cord segment 22.

FIGS. 4 and 5 illustrate an example of the use of the apparatus 12 ofFIG. 1 according to the method of the invention. In use, the apparatus12 is first manually passed through the abdominal wall 42, for examplethrough an incision or a cannula 44 in the abdominal wall 42, and ispositioned in the abdominal cavity 46 in the area of the first 48 andsecond 50 internal organs. In FIG. 4, the first internal organ 48represented is the human liver, and the second internal organ 50represented is the human stomach.

The third tissue connector 36 of the apparatus is then manuallyconnected to tissue 52 adjacent the first internal organ 48 and betweenthe first 48 and second 50 internal organs. In the example shown in FIG.4, the tissue 52 is the crus of the diaphragm. Connection of the thirdtissue connector 36 to the tissue 52 positions the second ends 18, 26 ofthe first 14 and second 22 cord segments connected to the third tissueconnector 32 between the first 48 and second 50 internal organs and onan opposite side of the first internal organ 48 from the abdominal wall42.

The first tissue connector 32 attached to the opposite end 16 of thefirst cord segment 14 from the third tissue connector 36 is thenmanually moved causing the length of the first cord segment 14 to moveand engage across the first internal organ 48. Continued movement of thefirst tissue connector 32 causes the first cord segment 14 engagingacross the first internal organ 48 to move the first internal organtoward a position away from the second internal organ 50. The firsttissue connector 32 is then manually connected to the inner abdominalwall 42.

The second tissue connector 34 attached to the opposite end 24 of thesecond cord segment 22 from the third tissue connector 36 is thenmanually moved causing the second cord segment 22 to move and engageacross the first internal organ 48. Continued movement of the secondtissue connector 34 causes the second cord segment 22 engaging acrossthe first internal organ 48 to move the first internal organ 48 towardthe position away from the second internal organ 50. The second tissueconnector 34 is then manually connected to the inner abdominal wall 42.

With the apparatus 12 connected between the tissue 52 and the innerabdominal wall 42 in the manner discussed above, the first cord segment14 and the second cord segment 22 engage across the first internal organ48 and hold the first internal organ 48 at the position away from thesecond internal organ 50 without further manual input. This providessurgical access to the second internal organ 50. Without requiringmanual holding or restraining of the first internal organ 48 in theposition away from the second internal organ 50.

FIG. 6 is a representation of the apparatus of FIG. 2 that has beenconnected between the tissue 52 and the inner abdominal wall 42according to the same method as the apparatus of FIG. 1 described above.

In a further embodiment of the apparatus of the invention shown in FIG.3, the apparatus 54 is comprised of a single cord 56 having a continuousflexible length with opposite first 58 and second 60 ends. A tissueconnector in the form of a needle 62 is attached to the first end 58 ofthe length of cord 56. At the opposite second end 60 of the length ofcord 56, the cord is formed in a knot 64.

The method of using the embodiment of the apparatus 54 shown in FIG. 3is illustrated in FIG. 7. The apparatus 54 is first positioned insidethe abdominal cavity in the same manner as the previously describedembodiments. The knotted end 64 of the length of cord is then connectedto the tissue 52 adjacent the first internal organ 48 by first passingthe needle 62 through the tissue 52 and then manually pulling the needle62 and the attached length of cord 56 through the tissue 52. Thisattaches the knotted second end 64 of the length of cord 56 to thetissue 52 between the first 48 and second 50 internal organs.

The needle 62 is then passed through the inter-abdominal wall 42 and theneedle 62 and the attached length of cord 56 are pulled from theinsertion site 72 back into the abdominal cavity 46. This causes a firstsegment 74 of the cord length 56 to move into engagement with and acrossthe first internal organ 48. The engagement of the first cord segment 74with the first internal organ 48 moves the first internal organ 48toward the position away from the second internal organ 50.

The needle 62 is then again inserted through the inter-abdominal wall 42at a second insertion location 76 spaced from the first insertionlocation 72. The needle 62 and the attached length of cord 56 are pulledmanually through the second insertion 76 into the abdominal cavity 46until an intermediate section of cord 78 extends between the twoinsertion sites 72, 76.

The needle 62 and the attached length of cord 66 are then passed throughthe knot 64 formed at the opposite end of the length of cord 56 and arepulled tight. This causes a second cord segment 82 of the length of cord56 to engage across and move the first internal organ 48 toward theposition away from the second internal organ 50. The length of cord 56is pulled tight and a knot is tied between the opposite ends of the cordat the knot 64 on the cord second end 60. The portion of the length ofcord 54 extending from the knot 64 to the needle 62 is then cut andremoved from the abdominal cavity. The length of cord 54 left in theabdominal cavity forms a triangular loop with the first 56 and second 82cord segments extending across the first internal organ 48 and holdingthe first internal organ in the position away from the second internalorgan 50 without manual input. In this manner, surgical access isprovided to the second internal organ 50 without manually holding thefirst internal organ 48 in its retracted position.

FIGS. 8A-8E represent one method of inserting the apparatus of theinvention into the abdominal cavity and the method of using theapparatus. The embodiment of the apparatus 12 shown in these drawingFigures has a pair of keith needles 80, 82 as the first and secondtissue connectors, and a “T” bar 84 as the third tissue connector. Theapparatus 12 is first positioned inside an insertion device 86 in theform of a hollow narrow tube. The insertion device 86 is then insertedthrough a trocar or cannula 44 that has been positioned in the abdominalwall 42 in a conventional manner. Once inside the abdominal cavity 46,the apparatus 12 is removed from the interior of the insertion device 86and the insertion device is removed from the abdominal cavity throughthe cannula 44. The “T” bar 84 or the third tissue connector is thenpassed through the body tissue 52, i.e., the right diaphragm crus asdescribed earlier. Once the “T” bar 84 is passed through the tissue 52,it is rotated to its substantially 90 degree position relative to itspathway through the tissue 52 as shown in FIG. 8C. The apparatus 12 isthen pulled from the keith needles 80, 82. As represented in FIG. 80,the keith needles 80, 82 are then passed through the abdominal wall 42and the apparatus is pulled tight against the first internal organ 48,i.e., the liver. The needles 80, 82 are then pulled at the exterior ofthe abdominal wall 42, causing the apparatus to move the first internalorgan 48 away from the second internal organ, i.e., the stomach. A pairof tension clasps 88, 90 are attached to the respective first 14 andsecond 22 cord segments of the apparatus on the exterior of theabdominal wall 42 to hold the apparatus in its position across the firstinternal organ 48 in the abdominal cavity 46.

FIGS. 9A-9E represent a method of using an embodiment of the apparatus12 that is similar to that shown in FIGS. 8A-8E and described above. Inthis example, the apparatus 12 also employs the “T” bar 84 as its thirdtissue connector. However, there is no needle provided on the first cordsegment 14 and there is no needle provided on the second cord segment22. In this embodiment of the apparatus 12, the first cord segment 14 isa length of suture having a free end 92 opposite the “T” bar 84 and thesecond cord segment 22 is a length of suture also having a free end 94opposite the “T” bar 84. The apparatus 12 is shown in FIG. 9A as beingpositioned in the abdominal cavity 46 using the insertion device 86 inthe same manner described earlier with reference to the method of FIGS.8A-8E. The apparatus 12 of FIG. 9A is also initially used according tothe same method of FIGS. 8A-8E in that the “T” bar 84 is passed throughthe body tissue 52 and is positioned substantially 90 degrees relativeto the pathway through the tissue. A pair of GraNee needles 96, 98 arethen passed through the abdominal wall 42. One of the GraNee needles 96grabs the suture free end 92 of the first cord segment 14 and the otherGraNee needle 98 grabs the suture free end 94 of the second cord segment22. The GraNee needles 96, 98 are then withdrawn through the abdominalwall 42 pulling the suture free ends 92, 94 through the abdominal wall.The suture free ends 92, 94 are then secured to the abdominal wall usinga pair of clamps 88, 90 as was done in the previously-describedembodiment of FIGS. 8A-8E.

FIGS. 10A and 10B are a representation of the method of the inventionpracticed using an ENDO STITCH® device marketed by United StatesSurgical Corporation. FIG. 10A represents the distal end of the ENDOSTITCH® 102 being inserted through the cannula 44 in the abdominal wall42 to a position adjacent the diaphragm crus 52. As is conventional, thepair of jaws 104, 106 at the ENDO STITCH® distal end 102 hold a needle108 and a length of suture 110. The ENDO STITCH® 102 is manuallyactuated to pass the needle 108 through the tissue 52 of the crus fromone jaw 104 of the ENDO STITCH® to the opposite jaw 106 of the ENDOSTITCH®. The length of suture 110 is then removed from the abdominalcavity 46 through the cannula 44 and is pulled tight, causing the lengthof suture 110 to move and hold the first internal organ away from thesecond internal organ in substantially the same manner as describedearlier.

FIGS. 11A and 11B represent a further embodiment of the apparatus 12 andits method of use. The embodiment of the apparatus 12 shown in FIGS. 11Aand 118 and its method of use are substantially the same as that ofearlier-described embodiments, except that the “T” bar of thepreviously-described embodiments is replaced by a “J” hook locking clasp112. FIG. 11A shows the locking clasp 112 in its open position prior tothe hook portion of the clasp being passed through the tissue 52 of thediaphragm crus. FIG. 116 shows the locking clasp 112 after the hook ofthe clasp has been passed through the tissue 52 and the clasp has beenlocked. The method of further using the apparatus to move and hold aninternal organ is substantially the same as that of earlier-describedembodiments.

FIGS. 12A and 126 show a further embodiment of the apparatus 12 and itsmethod of use. The construction of the embodiment of the apparatus 12shown in FIGS. 12A and 126 is substantially the same as earlierdescribed embodiments, except that the “T” bar or locking clasp isreplaced by a barbed needle 114. The method of using the embodiment ofthe apparatus shown in FIGS. 12A and 126 is substantially the same asthat of earlier described embodiments, except that the barbed needle 114is passed through the tissue 52 of the diaphragm crus until the barb ofthe needle emerges from the tissue as shown in FIG. 12B. This securesthe apparatus to the tissue 52. Further use of the apparatus to move andhold an internal organ is substantially the same as that ofearlier-described embodiments.

FIGS. 13A and 13B show a further embodiment of the apparatus 12 of theinvention that is substantially the same as that as earlier-describedembodiments except that the third tissue connector or “T” bar isreplaced by a resilient biased clasp 116. In the method of using theapparatus of FIGS. 13A and 13B, the opposite arms 118, 120 of the clasp116 are compressed to open the jaws 122, 124 of the clasp as shown inFIG. 13A. The jaws 122, 124 are then positioned around the tissue 52 ofthe diaphragm crus and are allowed to close, thereby securing the clasp116 to the tissue 52. The subsequent method of using the apparatus shownin FIGS. 13A and 13B is substantially the same as that ofpreviously-described embodiments of the apparatus.

FIG. 14A-14C show a further embodiment of the apparatus 12 that issubstantially the same as that of previously-described embodimentsexcept that the third tissue connector is a two-piece rivet assembly.The assembly is comprised of a pin 126 having an enlarged point 128 anda cap 130 having a circular center opening 132. In the method of usingthe apparatus of FIGS. 14A-C, the pin 126 is first inserted through thetissue 52 of the diaphragm crus until the point 128 projects from theopposite side of the tissue. The point 128 is then inserted through thecenter opening 132 of the cap 130, thereby securing the pin 126 and thecap 130 to the tissue 152. The subsequent steps of using the apparatusof FIGS. 14A-14C is substantially the same as that of earlier-describedembodiments of the apparatus.

FIGS. 15A and 15B show a further embodiment of the apparatus 12 that hassubstantially the same construction of earlier-described embodiments ofthe apparatus except for the first and second tissue connectors being apair of “J” shaped hooks 134, 136. In the method of using the embodimentof the apparatus shown in FIGS. 15A and 15B, the first cord segment 14and the second cord segment 22 are secured to the inner abdominal wall42 by passing the hooks 134, 136 through the tissue of the innerabdominal wall. Apart from this, the method of using the apparatus shownin FIGS. 15A and 15B is substantially the same as that ofearlier-described embodiments of the apparatus.

FIGS. 16A and 16B represent a further embodiment of the apparatus andits method of use that are substantially the same as that ofpreviously-described embodiments, except for the first and second tissueconnectors being a pair of “J” hook locking clasps 138, 140. In themethod of using the apparatus of FIGS. 16A and 166, the hook portions ofthe locking clasps 138, 140 are passed through the tissue of the innerabdominal wall 42 and then are locked closed. This secures the firstcord segment 14 and the second cord segment 22 to the inner abdominalwall. Apart from this, the method of using the apparatus of theinvention shown in FIGS. 16A and 16B is substantially the same as thatof earlier-described embodiments of the apparatus.

FIG. 17 shows a representation of an embodiment of the apparatus wherethe first and second tissue connectors are provided as a pair ofresilient, biased clasps 142, 144 that have substantially the sameconstruction of the earlier-described clasp 116. The clasps 142, 144 aresecured to the inner abdominal wall 42 by first opening the clasps andpositioning tissue of the inner abdominal wall between the open jaws ofthe clasps, and then allowing the jaws of the clasps to close over thetissue. This secures the first cord segment 14 and the second cordsegment 22 to the inner abdominal wall. Apart from this, the method ofusing the apparatus represented in FIG. 17 is substantially the same asthat as earlier-described embodiments of the apparatus.

FIGS. 18A and 18B show an embodiment of the apparatus and its method ofuse that is substantially the same as that of FIG. 7. The embodiment ofFIGS. 18A and 18B differs from that of the FIG. 7 embodiment in that thefree ends 146, 148 of the length of suture 150 are tied in a knotcompleting the triangular loop configuration of the length of suture 150at a location that is displaced from the portion of the suture 150passed through the tissue 52 of the diaphragm crus. Apart from this, themethod of using the apparatus of the invention shown in FIGS. 18A and18B is substantially the same as that of the embodiment of the apparatusshown in FIG. 7.

FIGS. 19A and 19B show a further embodiment of the apparatus and itsmethod of use. The apparatus shown in these drawing Figures is comprisedof a length of cord 152 with a circular pledget 154 secured at one endof the cord and a needle, for example a keith needle 156, secured to theopposite end of the cord. The cord 152 could be a length of suture orother similar material. In the method of using the apparatus shown inFIGS. 19A and 19B the needle 156 is first passed through the abdominalwall 42 and into the abdominal cavity 46. The needle 156 is then passedthrough the tissue 52 of the diaphragm crus. The needle 156 is thenagain passed through the abdominal wall 42 to the exterior of theabdomen and is pulled tight. This results in the length of cord 152engaging against and moving the first internal organ away from thesecond internal organ in substantially the same manner aspreviously-described embodiments. The tight length of cord 152 is thensecured in place by a clasp 158 attached to the length of cord 152against the exterior of the abdominal wall 42.

FIGS. 20A and 20B show a representation of a further embodiment of theapparatus and its method of use. In FIG. 20A, the apparatus is showncomprised of a length of cord 160 having a circular pledget 162 at oneend and a needle, for example a keith needle 164, at the opposite end.The apparatus also includes a second shorter length of cord 166 with a“T” bar 168 at one end and a loop 170 formed in the opposite end. In theembodiment, the cords 160, 166 may be suture or other similar materials.The method of using the apparatus is represented in FIG. 20B. The “T”bar 168 is first secured to the tissue 52 of the diaphragm crus. Theneedle 164 is then passed through the tissue of the inner abdominal wall42, through the loop 170 and then through the abdominal wall 42 to theexterior of the abdomen. Pulling the needle 164 on the exterior of theabdomen pulls the cord 160 tight across the internal organ to move andhold the internal organ in substantially the same manner as that ofpreviously-described embodiments of the apparatus.

FIGS. 21A and 21B show a further embodiment of the apparatus that issubstantially the same as that of the embodiment of FIGS. 20A and 20B,except that the needle 164 is removed from the end of the length of cord160, leaving a free end 172 of the cord. The method of using thisembodiment of the apparatus is substantially the same as that of thepreviously-described embodiment except for the step of passing the cordfree end 172 through the abdominal wall 32. A GraNee needle (not shown)may be used to perform this step of the method.

FIGS. 22A and 22B show a further embodiment of the apparatus that issubstantially the same as that of the previously-described embodiment,except that it is comprised of only the length of cord 160 having thecircular pledget 162 at one end and a free end 172 of the cord at theopposite end. In the method of using this embodiment of the apparatus,the suture free end 172 is first passed through the inner abdominal wall42, then through the tissue 52 of the diaphragm crus, and then throughand out of the abdominal wall 42. As in the previously-describedembodiment, the suture free end 172 can be passed through the tissue ofthe abdominal wall 42 and the crus 52 using a GraNee needle or othersimilar instrument. The length of cord 160 is pulled tight to move andhold the first internal organ relative to the second internal organ insubstantially the same manner as previously-described method embodimentsof the apparatus.

FIG. 23 shows a further embodiment of the apparatus that issubstantially the same as that of earlier-described embodiments exceptfor the first and second tissue connectors being “J” hook locking clasps174, 176 that incorporate one-way clutch mechanisms. The ends of thecord segments 14, 22 can be pulled through the clutch mechanisms of theclasps 174, 176 in one direction, but are prevented by the clutchmechanisms from being pulled through the clasps 174, 176 in the oppositedirections.

FIG. 24A-24C show representations of a “J” hook locking clasp such asthat shown in FIG. 23, with a one-way clutch mechanism. The one-wayclutch mechanism is comprised of a rotatable pulley 178 and a “V” shapedgroove 180 positioned adjacent the pulley 178. An end portion of thecord 182 is threaded through the “V” shaped groove 180 and then aroundthe pulley 178. When the end of the cord 182 extending from the pulley178 is pulled tight, the relative positions of the pulley 178 and thegroove 180 cause the portion of the cord 182 to wedge and become lockedin the bottom of the groove 180.

FIG. 25 shows a further representation of the embodiment of theapparatus employing a “J” hook locking clasp 184 with a one-way clutchmechanism. The one-way clutch mechanism is comprised of a pair ofpivoting cams 186, 188 having opposing ratchet tooth surfaces 190, 192.A portion of the apparatus cord 194 is threaded between the opposedtooth surfaces. The portion of cord 194 can be pulled through thespacing between the cam ratchet tooth surfaces 190, 192 in onedirection, for example to the left in FIG. 25, but the cams 186, 188pivot toward each other and their ratchet tooth surfaces 190, 192 clampthe cord portion 194 between the surfaces when the cord portion ispulled in the opposite direction, for example to the right as shown inFIG. 25.

FIG. 26 shows a representation of a further embodiment of the “J” hookclasp 196 having a one-way clutch mechanism. In this embodiment, theone-way clutch mechanism is comprised of a toothed wheel 198 thatengages with the cord portion 20 pulled through the claps 196. The toothwheel 198 also has a smaller ratchet wheel 202 at its center. Theratchet wheel 202 engages against a resilient pawl 204. The ratchetwheel 202 and resilient pawl 204 function in the conventional mannerallowing the toothed wheel 198 to rotate in one direction when the cordportion 200 is pulled through the clutch mechanism, for example to theright as shown in FIG. 26, but prevent the rotation of the toothed wheel198 and the movement of the cord portion 200 when the cord portion ispulled in the opposite direction, for example to the left as shown inFIG. 26.

FIGS. 27-32 show several different representations of the possibleconstructions of the cord segments 14, 22, 38 of the apparatus of theinvention. In FIGS. 27-32 the first and second tissue connectors arerepresented by needles, for example keith needles 80, 82. The thirdtissue connector is represented by a “T” bar 84. It should be understoodthat these are only examples of only three tissue connectors that couldpossibly be used with the apparatus of the invention, and that otherforms of tissue connectors, for example the types described herein couldbe used as the three tissue connectors on the apparatus.

FIG. 27 shows the first 14, second 22 and third 38 cord segments asbeing constructed of suture material.

FIG. 28 shows the first 14 and second 22 cord segments being part of asingle length of surgical tape or strap, and the third cord segment 38being constructed of suture.

FIG. 29 shows the first 14 and second 22 cord segments being constructedof lengths of suture inserted through lengths of surgical tubing. Thethird cord segment 38 is constructed of suture.

FIG. 30 shows the apparatus as having first 14 and second 22 cordsegments constructed of combinations of surgical tape and sutureconnected end to end. The third cord segment 38 is constructed of suturematerial.

FIG. 31 shows the apparatus being constructed of first 14 and second 22cord segments formed from a single length of suture material insertedthrough a single length of surgical tubing. The third cord segment 38 isconstructed of suture material.

FIG. 32 shows the apparatus as having the first 14 and second 22 cordsegments constructed of a single continuous length of surgical tapehaving lengths of suture at opposite ends. The third cord segment 38 isconstructed of suture material.

FIGS. 33-45 show examples of some of the various different types oftissue connectors that could be used as any one of the tissuesconnectors 32, 34, 36 of the apparatus. These are only some of thepossible types of tissue connectors, and the connectors shown in FIGS.33-45 should not be interpreted as limiting the apparatus to theparticular tissue connectors shown.

FIG. 33 shows a “T” bar 84 as one example of any one of the three tissueconnectors 32, 34, 36.

FIG. 34 shows a barbed needle 114 as any one of the three tissueconnectors 32, 34, 36.

FIG. 35 shows the two-piece rivet pin 126 and cap 30 connector that canbe used as any one of the three tissue connectors 32, 34, 36.

FIG. 36 shows the “J” hook locking clasp 112 that can be used as any oneof the three tissue connectors 32, 34, 36.

FIG. 37 shows the resilient, biased clasp 116 that could be used as anyone of the three tissue connectors 32, 34, 36.

FIG. 38 shows a cross-section of an embodiment of a “J” hook lockingclasp. The embodiment shown is comprised of a cylindrical housing 206that contains the “J” hook 208 and a coil spring 210 that biases the “J”hook 208 to its closed position.

FIGS. 39A-39C show a variation of the “J” hook locking clasp of FIG. 38where the coil spring 210 is replaced by a spiral band spring 212. FIG.39B shows the spiral and spring 212 in its extended configuration, andFIG. 39C shows the spring in its compressed configuration.

FIGS. 40A and 40B show a tissue connector clasp that is comprised of apair of resilient jaws 214, 216 that project from one end of a hollowhousing 218, and a pin 220 connected to the jaws that projects from theopposite end of the housing. A spring 22 contained in the housing 218biases the pin 220 and the jaws 214, 216 to the left as shown in FIG.40A. This causes the resilient jaws to move to their open position shownin FIG. 40A. Pulling the pin 220 to the right against the bias of thespring 222 causes the housing to slide against the opposite sides of thejaws 214, 216 and move the jaws to their closed position.

FIG. 41 shows a side view of the resilient biased clasp 116 describedearlier. Compressing the opposite arms 118, 120 of the clasp 116 causesthe jaws 122, 124 to separate. Releasing the compression force causesthe jaws 122, 124 to move together under the bias of the resilience ofthe clasp 116.

FIG. 42 shows an embodiment of a clasp comprised of a first jaw 224 andfirst arm 226 connected by a pivot connection 228 to a second jaw 230and second arm 232. An oblong cam 234 on a toothed cam wheel 236 ispositioned between the pair of arms 226, 232. A toothed actuator wheel238 meshes with the toothed cam wheel 236. Rotation of the actuatorwheel 238 will cause rotation of the cam wheel 236 and the cam 238.Rotation of the cam 234 to its position shown in FIG. 42 pushes the pairof arms 226, 232 away from each other which in turn causes the pair ofjaws 224, 230 to move toward each other. Rotation of the cam 234 90degrees or one-quarter turn from its position shown in FIG. 2 will causethe jaws 242, 230 to move away from each other.

FIG. 43 shows an embodiment of a clasp comprised of a first jaw 240 andfirst arm 242 connected by a pivot connection 244 to a second jaw 246and second arm 248. A spring 250 is positioned between the pair of arms240, 248 and biases the arms away from each other. This in turn biasesthe first jaw 242 and second jaw 246 toward each other. The jaws 242,246 are opened by applying a compression force to the opposite sides ofthe first arm 240 and second arm 248 that compresses the spring 250.

FIGS. 44A-44B show a side-sectioned view of a construction of the rivetassembly described earlier. As seen in the drawing Figures, the pin head128 is slightly larger in diameter than the cap hole 132. When the pin126 is attached to the cap 130, there is a fixed gap or maximum distancebetween a circular head 252 of the pin 126 and the cap 130.

FIGS. 45A-45E show a further embodiment of a rivet assembly. In thisassembly, the rivet pin 254 has several notches 256 along its lengthbetween the pin head 258 and the pin point 260. The rivet cap 262 issimilar in construction to that of the previously-described embodimentwith a center opening or hole 264 extending through the cap. However,the cap 262 is also formed with a transverse slot 266 that intersectsthe center hole 264 and a parallel slot 268 that extends into the cap262 parallel to the center hole 264 and intersects the transverse slot266. A locking tab 270 with a pin hole 272 and a spring hole 274 isinserted in the transverse slot 266 for sliding movement therein. Aresilient wire spring 276 is inserted downwardly into the parallel slot268 and through the tab pin hole 272. Inserting the rivet pin 254 intothe cap center hole 264 and through the tab pin hole 272 causes the pinto slide the tab to the left as shown in FIG. 45A against the bias ofthe wire spring 276. As a pin notch 256 passes through the tab hole 272,the bias of the spring 276 causes the tab 270 to move to the right andinto the notch 256. This locks the pin 254 in place relative to the cap262. With the pin 254 having a number of notches, and in the example ofFIG. 45A having three notches, the position of the pin head 258 relativeto the cap 262 can be adjusted between three positions. This provides anadjustable gap or an adjustable distance between the pin head 258 andthe cap 262.

FIGS. 46A-46E represent a further embodiment of the apparatus of theinvention. This embodiment is comprised of a length of cord 278 having aneedle 280 at one end and a loop 282 formed at the opposite end. Acircular pledget 284 is provided on the length of cord 278 toward theloop end of the cord. The apparatus also includes a locking collarhaving a hollow cylindrical housing 286 that contains a tubular one-waysuture lock 288. The suture lock 288 is basically cylindrical but isformed with a resilient tab 290 that projects toward the center of thecylindrical configuration of the suture lock. FIG. 46E shows across-section representation of the collar cylindrical housing 286containing the one-way suture lock 288 and a portion of the length ofcord 278 extending through the collar. The method of using thisembodiment of the apparatus is shown in FIG. 46C. In use in theabdominal cavity 46, the needle 280 is first passed through the tissue52 in the area of the diaphragm crus, and then is passed a first timethrough the inner abdominal wall 42. The needle 280 is then moved acrossthe inner abdominal wall 42 and is again passed a second time throughthe inner abdominal wall. The needle is then inserted through the loop282 and is pulled tight. This causes the length of cord 278 to form atriangular loop in the abdominal cavity that moves the first internalorgan away from the second internal organ and holds the first internalorgan in the displaced position in the same manner aspreviously-described methods of using the apparatus of the invention.The needle 280 is then passed through the collar cylindrical housing 286and the housing 286 is moved tight against the cord loop 282. The cordloop 282 is smaller than the housing 286 so that the housing cannot passthrough the loop 282. As the length of cord 278 is pulled through thecollar housing 286, the locking tab 290 engages against the side of thecord 278 as shown in FIG. 46E. This allows the cord 278 to move throughthe collar housing 286 in the direction to the right shown in FIG. 46E,but prevents movement of the cord to the left as shown in the Figure. Inthis manner, the apparatus of FIGS. 46A-46E holds the length of cordtight in its triangular loop configuration.

FIGS. 47A and 47B show a further embodiment of the apparatus of theinvention and its method of use. The apparatus is comprised of a lengthof cord 294 having a pledget 296 secured at one end and a needle 298secured at the opposite end. The apparatus also includes a one-waylocking mechanism 300 having a pair of channels 302, 304 through themechanism dimensioned to receive the length of cord 294. One of thechannels 302 allows the length of cord 294 to move through the channelin one direction, but prevents the opposite direction of movement. Theother channel 304 allows the length of cord 294 to move through thechannel in one direction, but also prevents the opposite direction ofmovement of the cord 294. As represented in FIG. 47A, the method ofusing the apparatus first involves the needle 298 passing through theinner abdominal wall until the pledget 296 is positioned up against thewall. The needle 298 then passes through the tissue 52 in the area ofthe diaphragm crus. The needle 298 is then inserted through the firstchannel 302 of the one-way locking mechanism 300. The needle 298 is thenagainst passed through the inner abdominal wall at a location spacedfrom the first insertion site and is then passed through the secondchannel 304 of the one-way locking mechanism 300. The needle 298 withthe length of cord 294 are then pulled tight and the locking mechanism300 is moved up against the inner abdominal wall at the second needleinsertion site. This causes the length of cord 294 to move the firstinternal organ and hold the first internal organ in its moved positionaway from the second internal organ in a similar manner to that ofearlier-described embodiments.

FIGS. 47C and 47D show the interior of one embodiment of the one-waylocking mechanism 300. The mechanism 300 includes a housing first half306 and a second half 308 that are connected together by a living hinge310. The open position of the locking mechanism is shown in. FIG. 47D.The interior of the two halves 306, 308 of the locking mechanism areformed with grooves 312, 314 that form the two channels 302, 304 throughthe locking mechanism when the two halves 306, 308 of the lockingmechanism are pivoted about the living hinge 310 and snapped together. A“U” shaped spring member 316 is positioned in the first lockingmechanism half 306. The spring member 316 has a pair of arms 318, 320that project from opposite sides of the spring member. Each arm 318, 320in turn has a resilient locking tab 322, 324 that projects outwardly atan angle from its respective arm 318, 320. The resilient tabs 322, 324are positioned to engage in sliding engagement along portions of thecord 294 that pass through the channels 302, 304. As shown in FIG. 47D,the one tab 322 will allow the cord 294 to slide across the tab in adirection from right to left as shown in the drawing Figure, but willprevent the reverse sliding movement of the cord. The other tab 324 willallow sliding movement of the cord 294 across the tab 324 in a left toright direction as shown in FIG. 47D, but will prevent the reversemovement of the length of cord 294.

FIGS. 48A-48D show a variant embodiment of the one-way locking mechanism300. As shown in FIG. 48A, the length of cord is passed through thelocking mechanism 328 in much the same manner as the earlier-describedlocking mechanism 300. However, the second channel 330 of the lockingmechanism 328 of FIG. 48A has a block 332 with a hole 334 positionedalong the channel. An inclined tooth 336 is positioned in the block hole334. The portion of the cord length 338 that extends through the lockingmechanism channel 330 also extends through the block hole 334. A spring340 in the locking mechanism 328 biases the block 332 and the tooth 336toward the portion of cord 338 extending through the locking mechanismchannel 330. Due to the inclination of the tooth 336, with the spring340 biasing the tooth 336 into engagement with the cord portion 338, thecord portion 338 can slide over the tooth 338 as it is moved in a leftto right direction as shown in FIG. 48C, but is prevented from moving inthe opposite direction. Pressing the block 332 into the lockingmechanism 328 against the bias of the spring 340 disengages the tooth336 from the cord portion 338 and permits the cord portion to move ineither direction through the locking mechanism 328.

FIGS. 49A and 49B show a further embodiment of a cord locking mechanism344 that is similar to that of FIG. 48A. A cross-section of a channel346 extending through the locking mechanism 344 is shown in FIG. 49A.The channel 346 is formed with pairs of ridges 348, 350 on oppositesides of the channel. A wave form spring 352 is positioned in thechannel 346. The spring 352 has grooves 354 formed through peaks formedin the wave form spring. The portion of the cord 356 passing through thelocking mechanism channel 346 also passes through the grooves 354 in thewave form spring 352. A button hole 358 is provided in the top of thecord locking mechanism 344 and a release button 360 is positioned in thehole. When the release button 360 is pressed in the hole 358, it engageswith the wave form spring 352 and compresses the spring to the positionshown in FIG. 49A. In this position of the spring 352 the cord 356 isfree to move in opposite directions through the locking mechanism 344.When the button 360 is released, the spring 352 moves upwardly from itsposition shown in FIG. 49A and portions of the spring 362 engage withthe cord portion 356 extending through the lock mechanism channel 346and hold the cord portion against the ridges 348 at the top of thechannel 346. This locks the cord portion 356 in the locking mechanism344.

FIGS. 50A and 50B show a further embodiment of a one-way cord lockingmechanism. The mechanism includes a housing 364 having a hole 366extending through the housing that is defined by a cone-shaped interiorsurface 368. A pair of lock members 370, 372 are positioned in thehousing hole 366. Each of the lock members 370, 372 have exteriorsurfaces 374, 376 that when the locking members are positioned together,define a truncated cone shape that fits within the cone-shaped interiorsurface 368 of the housing 364. The opposing interior surfaces 378, 380of the lock members 370, 372 are formed with mating peaks and valleys.As shown in FIG. 50B, a spring 382 biases the two lock members 370, 372into the cone-shaped interior surface 368 of the housing 364, therebycausing the lock member interior surfaces 378, 380 to move toward eachother. A portion of a cord length 384 extending through the opposinginterior surfaces 378, 380 of the lock members 370, 372 is preventedfrom moving in the upward direction as shown in FIG. 50B due to the biasof the spring 382. However, when the cord portion 384 is moved in theopposite downward direction as shown in FIG. 50B, the movement of thecord portion 384 causes the lock members 370, 372 to compress the spring382. This allows the lock member interior surfaces 378, 380 to move awayfrom each other and release the portion of the cord 384 for movementthrough the lock mechanism.

FIGS. 51A-51E show one method of inserting the apparatus of theinvention into the tubular insertion device 86 described earlier. Asshown in these drawing Figures, a length of suture 386 is looped aroundthe apparatus and is then pulled through the interior of the insertiondevice 86. The first 14 and second 22 cord segments are folded flatagainst each other and the additional cord segment 38 is folded overparallel with the first cord segment 14 and second cord segment 22. Theapparatus is then pulled by the suture loop 386 into the interior of theinsertion device 86 to the position shown in FIG. 51E.

FIGS. 52A and 52B show a further embodiment of an insertion device 390.The insertion device 390 has the configuration of an elongate narrow rodwith a pair of opposed grooves 392, 394 extending up one side of the rodfrom a distal end 396 of the rod. A third groove 398 is formed in a sideof the rod toward a proximal end of the rod. The third groove 398 ispositioned between the opposed pair of grooves 392, 394. According tothe method of using the insertion device 390, the first cord segment 14and second cord segment 22 of the apparatus 12 are positioned in theopposed pair of grooves 392, 394 that extend from the insertion devicedistal end 396. The additional cord segment 38 of the apparatus 12 ispositioned in the third groove 398 in the side of the rod. With thecords of the apparatus held in these grooves, the insertion device 390is then inserted through a cannula 44 to insert the apparatus 12 intothe abdominal cavity.

FIG. 53 shows a representation of a further embodiment of the insertiondevice 402 that is similar in construction to the previously-describedembodiment of the insertion device 390. The insertion device 402 of FIG.54 is also comprised of a pair of opposed grooves 404, 406 that receivethe first 14 and second 22 cord segments of the apparatus 12, and athird groove 408 that receives the additional cord segment 38 of theapparatus.

FIG. 54 shows a still further embodiment of an insertion device 410. Theinsertion device 410 has a rod-shaped length with a hollow distal end.The rod distal end is comprised of a first half 412 and a second half414 that are connected together by a living hinge assembly 416.According to the method of using the insertion device 410 of FIG. 54,the apparatus 12 is positioned in the interior of the first half 412with the first cord segment 14 and second cord segment 22 extendingparallel to each other, and the third cord segment 38 folded aver thefirst cord segment 14 and second cord segment 22. The second half 414 ofthe insertion device is then folded over the hinge assembly 416 andsnapped closed to prepare the insertion device 410 for insertion of theapparatus 12.

FIGS. 55A-55C show a mesh apparatus 420 that is designed to be used as apart of the apparatus of the invention. The mesh apparatus 420 isbasically comprised of a generally rectangular or trapezoidal-shapedpanel of surgical mesh 422 with a pair of axially aligned tubes 424 atone side and a pair of axially aligned tubes 426 at the opposite side.As shown in FIG. 55B, the mesh apparatus 420 can be rolled up around thepairs of tubes 424, 426 to reduce the size of the apparatus forinsertion through a cannula and into the abdominal cavity. FIG. 55Cshows the mesh apparatus 420 positioned in the abdominal cavity 46 andheld in place against the first internal organ 48 by one of thepreviously-described embodiments of the apparatus. It should beunderstood that any of the previously-described embodiments of theapparatus may be employed according to the method of the invention tohold the surgical mesh 420 in its position as shown in FIG. 55C.

As various modifications could be made in the constructions of theapparatus and the methods herein described and illustrated withoutdeparting from the scope of the invention, it is intended that allmatter contained in the foregoing description or shown in theaccompanying drawings shall be interpreted as illustrative rather thanlimiting. Thus, the breadth and scope of the present invention shouldnot be limited by any of the above-described exemplary embodiments, butshould be defined only in accordance with the following claims appendedhereto and their equivalents.

We claim:
 1. A method of moving a first body tissue comprising a liverof a patient to a position away from a second body tissue comprising astomach of the patient and then holding the liver at the position, themethod comprising: providing a first cord segment having a flexiblelength with opposite first and second ends and a second cord segmenthaving a flexible length with opposite first and second ends; providinga first tissue connector that is attached to the first end of the firstcord segment; providing a second tissue connector that is attached tothe first end of the second cord segment; providing a third tissueconnector that is attached to the second end of the first cord segmentand is attached to the second end of the second cord segment; insertingthe first and second cord segments and the first second and third tissueconnectors into an area containing the liver and stomach; connecting thesecond end of the first cord segment to a third body tissue adjacent theliver by attaching the third tissue connector to the third body tissueand connecting the first end of the first cord segment to a fourth bodytissue that is on an opposite side of the area containing the liver andstomach from the third body tissue by attaching the first tissueconnector to the fourth body tissue with the length of the first cordsegment extending across and moving the liver toward the position awayfrom the stomach; connecting the second end of the second cord segmentto the third body tissue adjacent the liver by attaching the thirdtissue connector to the third body tissue and connecting the first endof the second cord segment to a fifth body tissue that is on an oppositeside of the area containing the liver and stomach from the third bodytissue by attaching the second tissue connector to the fifth body tissuewith the length of the second cord segment; and engaging across andmoving the liver toward the position away from the stomach; whereby thefirst and second cord segments engaging across the liver hold the liverat the position away from the stomach without manual input.
 2. Themethod of claim 1 further comprising the steps of: providing at leastone of the first, second or third tissue connector in the form of atissue connector comprising a J-hook locking clasp.
 3. The method ofclaim 1 further comprising the steps of: providing at least one of thefirst, second or third tissue connector in the form of a tissueconnector further comprising a clutch mechanism operable to allow thecord segment secured to the tissue connector to be pulled through theclutch mechanism in a first direction and prevented by the clutchmechanism from being pulled in a second direction opposite the firstdirection.
 4. A method of moving, within the abdomen of a patient, theliver of the patient to a position away from the stomach of the patientand then holding the liver, said method comprising: inserting into theabdomen of the patient a device comprising a cord having first andsecond ends, a first connector secured to the cord at the first end ofthe cord, and a second connector secured to the cord at a mid-pointbetween the first end and the second end, and a third connector securedto the cord at the second end of the cord, thereby defining a first cordsegment between the first and second tissue connectors and a second cordsegment between the second and third tissue connectors; securing thesecond connector to the diaphragm crus of the patient, thereby securinga midpoint of the cord to the diaphragm crus of the patient; passing thefirst cord segment and second cord segment between the liver and thestomach securing the first tissue connector to the abdominal wall, andsecuring the third tissue connector to the abdominal wall, whereby thefirst and second cord segments engage the liver to hold the liver at theposition away from the stomach.
 5. The method of claim 4, furthercomprising: disconnecting the second tissue connector from the diaphragmcrus of the patient, and disconnecting the first tissue connector fromthe abdominal wall, and disconnecting the third tissue connector fromthe abdominal wall; and removing the device from the abdomen.
 6. Themethod of claim 4 further comprising the steps of: providing at leastone of the first, second or third tissue connector in the form of atissue connector comprising a J-hook locking clasp.
 7. The method ofclaim 4 further comprising the steps of: providing at least one of thefirst, second or third tissue connector in the form of a tissueconnector further comprising a clutch mechanism operable to allow thecord segment secured to the tissue connector to be pulled through theclutch mechanism in a first direction and prevented by the clutchmechanism from being pulled in a second direction opposite the firstdirection.
 8. A method of moving, within the abdomen of a patient, theliver of the patient to a position away from the stomach of the patientand then holding the liver, said method comprising: inserting into theabdomen of the patient a device comprising a first cord segment and asecond cord segment, each having first and second ends, a firstconnector secured to the first cord segment at the first end of thefirst cord segment, and a second connector secured to the second ends ofboth the first cord segment and the second cord segment, and a thirdconnector secured to the second cord segment at the first end of thesecond cord segment; securing the second connector to the diaphragm crusof the patient, thereby securing the second ends of both the first cordsegment and the second cord segment to the diaphragm crus of thepatient; passing the first cord segment and second cord segment betweenliver and the stomach; securing the first tissue connector to theabdominal wall, and securing the third tissue connector to the abdominalwall, whereby the first and second cord segments engage the liver tohold the liver at the position away from the stomach.
 9. The method ofclaim 8, further comprising: disconnecting the second tissue connectorfrom the diaphragm crus of the patient, and disconnecting the firsttissue connector from the abdominal wall, and disconnecting the thirdtissue connector from the abdominal wall; and removing the device fromthe abdomen.
 10. The method of claim 8 further comprising the steps of:providing at least one of the first, second or third tissue connector inthe form of a tissue connector comprising a J-hook locking clasp. 11.The method of claim 8 further comprising the steps of: providing atleast one of the first, second or third tissue connector in the form ofa tissue connector further comprising a clutch mechanism operable toallow the cord segment secured to the tissue connector to be pulledthrough the clutch mechanism in a first direction and prevented by theclutch mechanism from being pulled in a second direction opposite thefirst direction.